Online Tools Aid Mental Health Wellness, Treatment

Liam Davenport

March 17, 2016

MADRID — Internet-based wellness trackers and online interventions can reach targeted groups of patients and achieve significant symptom improvement, new research shows.

Here at the European Psychiatric Association (EPA) 24th Congress, investigators from Madrid, Spain, presented results showing that a wellness tracker may allow the development of tailored therapies to specific patient groups by using patient profiles.

A second presentation showed that Internet-based cognitive-behavioral therapy (CBT) modules, tested in Ireland, achieved significant reductions in depressive symptoms that were sustained over 6 months.

Real-time Monitoring

In the first presentation, Covadonga Bonal-Giménez, a trainee in psychiatry and mental health at IIS-Fundación Jiménez Díaz, Madrid, Spain, defined electronic mental health care as "mental health services and information delivered or announced through the Internet and related technologies."

This can consist of computerized interventions, therapeutic virtual reality or gaming, telehealth and telemedicine, peer support via social media, and the evaluation of patient symptom data through Web tools, smart phones, e-technologies, and wearable technologies.

Bonal-Giménez then discussed MEMind, a mental state tracking e-tool developed at her institution that is available for use in smartphones, tablets, and desktop computers. It has a "personal health record" view that is initiated and maintained by the patient. According to the investigators, "having access to real-life and real-time patient monitoring will allow identification of relapse signatures and acute symptom triggers and objectively monitor the effectiveness and side effects of treatments."

The tool has two interfaces, an electronic health record view for clinicians, and an assessment view for patients.

The patient interface consists of three tabs. The first, called 'How are you today?,' contains questions on eating, sleeping, and subjective quality of life. The second contains 12 items from a general health questionnaire. The third is a free text area in which patients can write notes.

To determine the sociodemographic and clinical profile of the users and to identify any variables that would predict usage, Bonal-Giménez and colleagues invited all patients attending their institution's psychiatry unit over a 1-year period to register for MEMind.

The patient was informed about the study by their clinician. Patients who agreed to participate gave informed consent and received a personal username and password for the site.

Over a 1-year period, 13,811 patients were analyzed. Of these, 20.5% accessed MEMind on at least one occasion.

Individuals who used the website were significantly younger than those who did not (average age, 42.2 years and 48.5 years, respectively; P = .000). Website users were also significantly less likely to be male than nonusers (35.3% vs 38.6%; P = .001).

Users were more likely to have a diagnosis of a neurotic disorder in comparison with nonusers (57.9% vs 46.7%; for P = .000), to express a desire to die (24% vs 16.2%; P = .000), and to have suicidal ideation (12.0% vs 9.2%; P = .000).

"Knowledge of the user profile can aid in the design of strategies to implement electronic mental health resources," said Bonal-Giménez. She added that the population she identified could have tailored interventions developed for them.

She concluded that future strategies will focus on increasing user uptake, potentially by adding gaming, by using personalized questionnaires, and by incorporating an interface for family and caregivers. She and her colleagues will also look at adding treatment options and automatic warning messages for clinicians.

Internet-Based CBT

In the second presentation, Derek Richards, PhD, director of clinical research innovation, SilverCloud Health, and the School of Psychology, Trinity College Dublin, Ireland, reported results of a randomized, controlled trial of an Internet-delivered treatment for individuals with symptoms of depression.

He explained that low-intensity, Internet-delivered intervention is not a model of treatment that has been implemented widely across Europe. It is most commonly seen in the United Kingdom.

This model, he noted, recognizes that "not everyone needs a high-intensity course of treatment, such as psychiatric visits, or, indeed, visits to clinical or counseling psychology." Among the many types of intervention, a more recent addition has been the online delivery of standard CBT via interactive multimedia.

For the current analysis, the investigators studied an Internet-delivered CBT intervention called Space From Depression, which was developed by SilverCloud Health in Ireland.

From 641 potential recruits, the researchers randomly assigned 188 eligible patients with symptoms of depression to either the treatment group (n = 96) or a waiting-list control group (n = 92). The treatment consisted of eight modules of CBT, which offered the core treatment components.

"Importantly, it was a supported intervention. The literature in this area is clear: you'll achieve some effect with a self-administered intervention, but if you add support, the nature, type, and duration of which is still under large debate, you will increase the outcome or potential of the intervention," said Dr Richards.

The mean age of the participants was 39.86 years, and 73% were women. There were no significant baseline differences between the treatment group and the waiting-list control group.

There was, however, a greater rate of attrition in the treatment group, with 63% available immediately post treatment vs 100% of control participants. At the 3- and 6-month follow-ups, 52% and 30% of treatment group participants were available.

Dr Richards told the audience that, across all patients, a total of 1415 online CBT sessions were completed, with an average of 14.7 sessions per user. The mean time spent on the program was 5 hours and 22 minutes, and the average session length was 20.5 minutes. Of note, only 38% of treatment patients completed all eight CBT modules; 65% completed the first five.

The results indicated that a reliable change in symptoms, defined as a >9-point change on the Beck Depression Inventory (BDI-II) at posttreatment assessment, was achieved by 29% of treatment group participants vs 7.6% of control participants (P = .000).

More treatment participants achieved recovery, defined as a having a score of <10 and a change of >9 points on the BDI-II at posttreatment assessment (23% vs 4%; P = .000). Crucially, both improvements were maintained at 3- and 6-month follow-up.

Dr Richards noted that the levels of reliable change and recovery associated with the intervention were similar to those reported in previous studies with CBT.

He pointed out that one of the interesting aspects of the intervention was that it allowed individuals to determine "their required dose," potentially helping to keep them engaged. However, all the participants were self-referred, which points to the need for digital literacy and access to be able to use such interventions.

Dr Richards observed that "results need to be considered with care," inasmuch as the study only included patients with mild to moderate symptom severity, and the rate of attrition at 6 months was high.

Useful, Cost-effective

Technologies such as these are "really very useful," said Maria Paz García-Portilla Gonzalez, MD, PhD, Department of Psychiatry and Centro de Investigación Biomédica en Red de Salud Mental, University of Oviedo, Spain, who chaired the session.

"I hope that they will help us to attend to many patients, and I think it's a great tool for almost every kind of patient," she told Medscape Medical News.

"You know, you can use different tools for different patients, for example, in patients with phobias, patients with difficulties with relationships, and also for things like anxiety, depression. It's not only mild patients that can benefit from these tools."

Dr García-Portilla Gonzalez noted that online tools could also help patients who live in rural or remote areas.

"I think national health systems have to include this [type of] tool, because you can provide care to the population, and its cheaper than if they have to come to the clinics in the cities," she added.

Derek Richards is an employee of SilverCloud Health and Trinity College Dublin and has received research funding from SilverCloud Health and Aware Charity. No other significant financial relationships have been reported.

European Psychiatric Association (EPA) 24th Congress: Presented March 13, 2016.


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